We would rather be ruined than changed;
We would rather die in our dread
Than climb the cross of the moment
And let our illusions die.
-W. H. Auden

The topic in this booklet focuses on the aftereffects of interpersonal trauma. There is considerable evidence that survivors of interpersonal trauma experience a variety of effects from their experiences with interpersonal trauma. Some of these effects are characterized by feelings of isolation and alienation, feelings of stigmatization and being different from others, fear of intimacy and avoidance of relationships, and an inability to trust others. These result not only in problems in general social relationships, but also in relationships with men, women, and parents. Problems with partners in a close relationship may also arise, with a high incidence of revictimization. In addition, there is some evidence that survivors experience problems in their own parenting skills and their relationship with their children.

Who are the Survivors?

     Interpersonal trauma and abuse takes place everyday. The victims of abuse are of all ages, races, and socioeconomic strata. However, this section will focus more upon a more specific type of interpersonal abuse; childhood maltreatment. In general, the child victims of abuse and neglect are relatively young (average age is 7.4 years). Neglect is most often reported when children are quite young (infancy and toddlerhood), with incidence declining with age. In contrast, reports of sexual and emotional maltreatment occur most frequently among older, school-aged children and adolescents. Physical abuse affects a sizable portion of all age groups. The highest rate of physical injury, however, is found among the older children (12-17 years of age). Although this latter finding seems surprising in light of the public image of this problem centering on small children, it corresponds with increasing parent-child conflict that occurs during adolescent development.

     With the exception of sexual abuse (where females comprise 85% of the victims), boys and girls are reported at approximately the same rate for physical abuse and neglect. Race of the victim seems to be representative of the population at large.
 

Long-Term Aftereffects of Interpersonal Abuse:
Behaviors and Relationship Response

     While no single pattern of distress can be said to exist among all adult survivors of interpersonal trauma, a number of patterns of behaviors appear to be prominent among adult survivors. Taken together, the studies of interpersonal abuse in the literature provide strong support for the behavioral and psychological toxicity of interpersonal abuse. It appears, in this regard, that interpersonal trauma can have relatively direct and sustained impacts on psychological functioning as well as motivating behaviors that, while immediately adaptive, often have longer-term self-injurious consequences (for instance, substance abuse, eating disorders, self-mutilation).

Intimacy Disturbance

     Research and clinical observation suggest that interpersonal abuse is  associated with long-term alterations in social functioning. Adult survivors of interpersonal trauma report poor social adjustment, feelings of isolation, fear and distrust of others, and difficulty in forming and sustaining intimate relationships. Experiencing repeated uncontrollable life events decreases an individual’s ability to perceive future relationships as supportive or helpful and may, therefore, lead to greater difficulty in establishing trust in others.

     Adult survivors oftentimes see themselves as unworthy of relationships with people they consider good or healthy. It is believed that survivors oftentimes may attempt to gain mastery over their abuse experience by re-creating it in the form of involvement with abusive others.

     Sexual intimacy is often reported as a problematic area for survivors of interpersonal abuse. Such problems may present themselves as sexual dysfunction related to fears of vulnerability and revictimization, a general distrust of sex partners and men or women in general, a tendency to be dependent on or over-idealize those with whom they form close relationships, and a history of multiple, superficial, or brief sexual relationships that quickly end as intimacy develops.

     Perhaps one of the most disruptive and painful aspects of childhood interpersonal abuse is its impact on the survivor’s ability to trust. Requiring as it does a suspension of defensive activities and an assumption of safety at the hands of another, trust is especially difficult for survivors who were maltreated as children. The untreated survivor’s expectation of continued victimization, difficulties with trust, adversarial perspective, and tendency to “overreact” to perceived rejection or devaluation may lead to considerable isolation from and rejection by others.

 Revictimization

     When survivors do form close or long-term stable relationships, they may compulsively attach themselves to partners who frequently resemble the abuser. One possible explanation may be that the survivor has not learned the necessary skills either to protect himself/herself adequately, or to assert himself/herself in a relationship. The survivor’s expectation of what constitutes a “good” relationship, and the survivor’s rights within that, may have become distorted. Another explanation for revictimization may be that trauma can be repeated on behavioral, emotional, and physiological levels. The confusion of pain and love may cause individuals to develop strong ties with people who are physically, emotionally, or sexually threatening to them. In the presence of overt threat, the survivor may experience a return of the earlier interpersonal trauma and thus return to primitive and archaic behavior patterns.
 

Use of Psychoactive Substances

     Studies indicate that substance abuse is often inextricably associated with chronic experiences of interpersonal abuse, trauma, maltreatment, and pain, and that such substances are often used for temporary relief of--and survival despite--post-abuse trauma. Often even more powerful than dissociative states, alcohol and psychoactive drugs are immediate “painkillers” for many individuals who suffer anxiety, depression, or upsetting memories.

The acute effects of alcohol and drugs are manifold:
 

temporary elimination of emotional turmoil and pain

inducement of some level of euphoria or well-being

interference with memory of painful events

provision of an opportunity to express otherwise inhibited painful feelings

an opportunity for the user to develop a minimally demanding peer group

Tension Reducing Behaviors

     Over time, the survivor learns to deal with acute or impending abuse-related distress by quickly resorting to distracting, calming, or anesthetizing behaviors. Indiscriminate and frequent sexual activity, substance abuse, bingeing or chronic overeating, spending sprees, risk-taking activities, and self-mutilation are common behaviors that survivors find themselves involved with. In the face of extreme abuse-related distress, often restimulated by revictimization and/or perceived abandonment or rejection, the survivor may engage in any number of external activities that anesthetize, soothe, interrupt, or forestall painful emotional states.

Compulsive Sexual Behavior

     Also found among some abuse survivors are periods of frequent, short-term sexual behaviors, most typically with a number of different sexual partners. The choice of multiple sexual partners by some survivors appears to represent powerful needs for closeness and intimacy, as a result of deprivation in these areas in the past, and yet, fearfulness regarding the vulnerability inherent in sustained intimacy. As well, compulsive sexual behavior can be utilized to temporarily soothe, mask, or dispel chronic abuse-related dysphoria. Many abuse survivors report involvement in “one-night stands” or repetitive masturbation during times of depression, loneliness, or perceived abandonment or rejection by others, or during periods of uncontrollable rumination and recall of abuse-related painful events. These behaviors may be viewed as consciously or unconsciously chosen coping mechanisms invoked to modulate painful internal experiences rather than inappropriate behavior.

Long-Term Aftereffects of Interpersonal Abuse:
Psychological Responses

     Significant psychological distress may be a long-term aftereffect of interpersonal abuse. Interpersonal abuse can be so potentially hurtful during childhood since the abuse is taking place at the most critical developmental times for the child. It is during childhood when assumptions about self, others, and the world are being formed; when their relations to their own internal states are being established; and when coping and affiliate skills are first acquired.

Posttraumatic Effects

     Especially prominent for interpersonal abuse survivors are post-traumatic stress disorder-related intrusive symptoms. The most disturbing of these, by virtue of their uncontrollability and perceived bizarreness, are flashbacks. These sudden, intrusive sensory memories often include visual images of the abuser’s face or aspects of the actual interpersonal assault taking place, hearing the perpetrator’s voice, choking sensations related to forced oral intercourse, smelling the perpetrator’s alcohol-laden breath, and feeling hands grabbing one’s legs, thighs, or genitals.

     Repetitive, intrusive thoughts and/or memories of interpersonal victimization are common for survivors. Typically, intrusive thoughts center around themes of danger, humiliation, sex, guilt, and badness. Intrusive memories usually involve unexpected and unwanted   recollection of specific abusive or traumatic events in seemingly unrelated contexts.

     The post-traumatic symptoms of abuse survivors appear to involve more autonomic arousal (e.g., tension, “jumpiness,” flinching), avoidance of abuse-related thoughts or stimuli, violent nightmares, and intrusive thoughts of being violent or of suddenly being injured than do those produced by interpersonal abuse alone.

 Cognitive Distortions

     Psychologists generally agree that people make significant assumptions about themselves, others, the environment, and the future based upon childhood learning. Because the experiences of former child interpersonal abuse survivors are by definition usually negative, these assumptions and self-perceptions are often distorted. As an example, survivors may overestimate the amount of danger or adversity in the world, and underestimate their own self-efficacy and self-worth.

     It is believed that abuse-related negative cognitions probably arise from two sources: psychological reactions to abuse-specific events, and the survivor’s attempt to make sense of the abuse.

Abuse-Specific Responses

     Perceptions of helplessness and chronic danger are thought to result from the fact that the abuse occurred when the victim was more often than not a child, and thus physically and psychologically unable to resist or defend against the abuser. Because such experiences were often chronic and ongoing, feelings of hopelessness regarding the future were also likely. Similarly, the child may have made assumptions about his or her inherent badness, based on misinterpretation of maltreatment as, in fact, punishment for unknown transgressions.

     A common impact of interpersonal victimization is hypervigilance to danger--not only for potential physical injury, but also for psychological trauma such as betrayal, abandonment, or injustice. This expectation of injury may lead to hyperactivity in the presence of real, potential, or imagined threats. Not only do survivors identify potential abandonment in the everyday actions of significant others, they tend to respond to such perceptions with greater emotional or behavioral intensity than others might deem appropriate.

     Finally, negative self-evaluation may arise from the survivor’s attempt to make sense of his/her abuse. This process can lead to self-deprecating conclusions, including that one deserved the abuse and is inherently bad. Such cognitive reactions to child abuse and the resultant attempts to draw logical conclusions from it appear to produce what initially seems illogical: passivity, self-blame, and low self-esteem as a result of being unfairly treated by another. The extent of self-hatred that these dynamics can engender is often startling, as is its endurance during treatment. This dynamic is sustained seemingly by the self-perpetuating belief that “I was (and continue to be ) hurt because of my badness, and evidence of my badness is that I have been (continue to be) hurt.”

Altered Emotionality

     Depression. Study after study indicates that depression is the symptom most commonly reported among adult survivors of interpersonal abuse. Clinical experience suggests that adults with histories of interpersonal abuse are more prone to major depressive episodes as well as dysthymia, which is a milder form of depression characterized by chronic sadness and unhappiness, low self-esteem, self-blame, and perceived helplessness.

     Anxiety. Because interpersonal abuse is, by its nature, threatening and disruptive, it should not be surprising that survivors of such maltreatment are prone to feelings of fearfulness or anxiety, even well after abuse has transpired. Clinical experience suggests that adults with histories of interpersonal abuse frequently present with cognitive, classically conditioned, and somatic components of anxiety. Abuse-related anxiety typically involves 1) hypervigilance to danger in the environment, whether objectively warranted or not; 2) preoccupation with control, with the belief that even a slight loss of self-determination or self-protection could lead to danger or catastrophe; and 3) misinterpretation of objectively neutral or positive interpersonal stimuli as evidence of threat or danger.

     Dissociation. Dissociation can be thought of as a defensive disruption in the normally occurring connections among feelings, thoughts, behavior, and memories, consciously or unconsciously invoked in order to reduce psychological distress. It can be hypothesized that dissociation is a very functional dynamic for the survivor. This dynamic can help the survivor escape from the constraints of reality. Dissociation can provide a means of containing traumatic memories and emotions outside of normal conscious awareness, and is a means by which the survivor can create an alteration or detachment of sense of self in order that trauma happens to someone else or a depersonalized self. Finally, dissociation can provide an analgesia or means of reducing the emotional pain.

     There are three common types of dissociation that take place which relate specifically to alterations in thoughts, feelings, or awareness. They are disengagement, detachment/numbing, and observation. Disengagement involves a cognitive separation of the individual from his or her environment at times of stress or trauma. Detachment refers to the instances when an individual copes with the intensity of negative feelings associated with certain thoughts, memories, or ongoing events, by emotionally shutting down. This allows an individual to engage in necessary activities without being distracted or immobilized by psychological pain. Finally, observation occurs when individuals experience themselves as watching (as opposed to participating in) events in which they are directly involved.

Philosophy of Treatment

     The most important truism of interpersonal trauma recovery is that the individuals who were abused are survivors. These individuals have persevered despite often extreme interpersonal trauma and later abuse-related difficulties. The most important underlying premise of abuse-focused treatment is the individual I work with is not mentally ill or suffering from a defect, but rather is an individual whose life has been shaped in part, by ongoing adaptation to a toxic environment. Thus, my goal of therapy is less the survivor’s recovery than his or her continued growth and development. In this respect, it is critical that therapy be a process that utilizes the strengths and already existing skills of the client to move beyond his/her current level of adaptive functioning.

 Wound Care: Awareness and Integration

     Awareness and integration are the twin foci upon which treatment is predicated. Treatment is a supportive and safe effort at facilitating an integrated awareness of the present and the past, of previously split-off or compartmentalized internal experience. Through dissociation, avoidance, denial, and other defensive strategies, the survivor can devote considerable psychological resources to reduction of abuse-related pain.

     My approach to treatment endorses an entirely different set of principles. I emphasize the necessity of greater awareness of the past and present. Among the tasks inherent in the process of reworking the abuse period is the survivor’s ability to experience simultaneous contradictory feelings (e.g., anger and love, or fear and rage) without defensively dampening one and intensifying the other, or rapidly alternating between the two. I think it is important that the survivor develop the capacity to experience painful events directly without reflexive defensive operations such as dissociation or denial. The end result of this psychological healing is the survivor will experience greater psychological functioning in the “here-and-now” where problem solving and adjustment are usually preferable to defensive avoidance.

Goals of Treatment

My goals in working with any client are 1) the client experience relief from his/her symptoms, 2) the client experience resolution of any intrusive traumatic memories that he/she may be experiencing, 3) the client acquire a hopeful and nonsymptomatic orientation toward the future. These end results are the outcome of a therapeutic process that strongly emphasizes an active utilization of the client’s present life resources and images of future goals and possibilities. Such a process is predicated upon the assumption that any construction of a solution is a joint process between client and therapist, with the therapist taking responsibility for empowering the client to create and experience his/her own uniquely meaningful and effective therapeutic changes.

Resolving Interpersonal Trauma

     The resolution of interpersonal abuse and trauma is a very complex, yet very achievable process. When working with survivors of interpersonal trauma, I think of resolution in the following way:

1) Providing stabilization and relief for the client from symptoms stemming from or related to the interpersonal trauma.

2) Altering feelings associated with memories of trauma, so that the memories and/or flashbacks are no longer intrusive or painfully prevalent in the client’s daily life.

3) Developing a positive, practical, and healthy future orientation that results in nonsymptomatic patterns and, more importantly, in the client living what he/she would consider a “satisfying” life.

 Conclusion

     In general, the process of resolution therapy for interpersonal abuse and trauma is of a long-term, rather than a short-term nature. Long-term treatment is seen as needed because of the generally pervasive effects of the abuse, the compounding of effects over time, and the complexities of post-traumatic responses. Because of the intensity of emotions inherent in trauma, uncovering must proceed at a pace that is tolerable to the survivor. The unique characteristics and dynamics of interpersonal trauma demand a unique treatment approach which must be individualized to the survivor. This involves not only the use of a broad range of techniques but also a multimodal and integrated treatment approach. Whichever techniques or modalities are employed, they must reflect a comprehensive approach which encompass the emotional, cognitive, and behavioral components inherent in the difficulties experienced by individual survivors. Each of these components represents aspects of the traumagenic impact of interpersonal trauma and contribute in varying degrees to the long-term psychological and behavioral effects of the trauma. The healing process for adult survivors is complete when the survivor no longer feels contaminated by the survivor’s thoughts and behavior patterns. Instead of the abuse exerting control over the survivor’s life in eliciting  unconscious, maladaptive archaic behavior patterns, the survivor is able to take control of  his/her life and make his/her feelings and thoughts conscious, enabling the survivor to make choices rather than being internally driven or directed. The survivor has learned to trust himself/herself and his/her perceptions and not be fearful of taking risks in expressing and exploring his/her new self. The survivor will be able to embrace life by reclaiming their personhood, their sexuality, and the unpolluted self which has been in hiding since commencement of the interpersonal trauma.

What Can Family Members of Survivors Do?

 Beverly Engel, in  her book, Partners in Recovery, lists the following things for loved ones of survivors to do.

Learn all you can about abuse and the healing process

Believe what the survivor tells you

Allow the survivor time and space to express her anger

Allow the survivor to blame others for awhile

Allow the survivor time and space to express her/his pain

Rrespect the time and space it takes to heal

Understand that you will have to earn the survivor’s trust

Don’t try to rescue the survivor or do his/her healing for her        

G.B.U.

Steve

Dr. Steve Frisch, Psy.D. is a clinical psychologist in private practice in Chicago, Illinois and Northfield, Illinois. You can contact Dr. Frisch, Psy.D. at drfrisch@aliveandwellnews.com  or at (847) 498-5622. Recover from chemical dependency and its toxic impact on family members. Raise your children to choose to be alcohol and other drugs free. Learn how to in Dr. Frisch’s, Psy.D. Recovery book series.